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Intake form for screening new prospective clients
Referral Source*Contact Name*Contact Number*Client Name*Contact Number*Date*Street Address*City, State*Zip Code*D.O.B.*Age*Please enter a value between 0 and 100.Gender*MaleFemaleRace*SSN#*Medicaid#*Guardian Name*Contact Number*PLEASE CHECK THE SYMPTOM(S) AND BEHAVIOR(S) INDIVIDUAL IS DISPLAYING*
Short Attention Span
Inability to follow directions
Thoughts of harming self/others
Inability to complete tasks
Need community resources
Poor communication skills
Poor conflict resolution skills
Victim of Abuse
Homeless/Out of home placement
Poor peer relational skills
Inability to concentrate
Need for public assistance
Community Support (basic living skills)
Substance Abuse Treatment
Target Case Management Services
Method Of Payment*Medicaid/HMOSelf Pay/Private Insurance/OtherReasons for referral*
Is the individual/family currently at risk of harm to self or others?*YesNoIf you checked yes in the previous question, Please explain?
Is the individual/family currently receiving: Behavior Health Services*YesNoIf you answered yes in the previous question, Please explain?
PhoneThis field is for validation purposes and should be left unchanged.